Doctors and the Pharmaceutical Industry: Too Close for Comfort

1
Doctors and the Pharmaceutical Industry Too
Close for Comfort?

• Joel Lexchin MD
• School of Health Policy and Management
• York University
• Emergency Department
• University Health Network

2
Points To Cover

• Who has what interest?
• Promotion
• Samples
• Gifts, trips and other interactions
• Medical journals
• Doctors attitudes

3
What Is The Obligation of Industry?

• Make the maximum profit for shareholders without
  breaking the law
• This is neither good nor bad
• Industry is amoral, i.e., neither immoral nor
  moral

4
What Is the Obligation of Doctors?

• To do the best job (in prescribing) for our
  patients

5
The Question

• Are the obligations of doctors and industry
  always compatible?

6
Promotion
7
Spending on RD and Promotion, 2004

• Promotion
• 16 of sales
• 2.22 billion

• RD
• 8.5 of sales
• 1.17 billion

8
Canadian Promotion, 2000
IMS Canada, 2001
9
New Drugs Are Often Heavily Prescribed
IMS Canada, 1999
10
No Comparative Information and Short-Term Testing
Only

• 16 new active substances launched in
• Canada 1990-2000
• 5 tested only against placebo controls
• Small numbers of patients, e.g., when risperidone
  marketed 2 published trials with 1-49 patients
  and one with 49-99 patients
• Out of 129 published trials
• 34 lt4 weeks
• 9 gt26 weeks
• E.g., no olanzapine trial longer than 26 weeks
• Lexchin. Can Fam Physician 2002481487-92

11
Safety Issues Often Arise (United
States,1975-1999)
Half of withdrawals occur within 2 years of
launch
Lasser et al. JAMA 20022872215-2220
12
Optimal Doses are Often Not Known
Pharmacoepidemiology and Drug Safety
200211439-46
13
Pharmaceutical Sales Reps in Canada

• 4000 in 1996
• Jewesson et al. Can J Hosp Pharm 199649256-60

14
Doctors Attitudes Towards Sales Reps
1995 survey of 262 doctors, 1 strongly agree, 5
strongly disagree
15
Doctors Desired Method of Receiving Drug
Information
1995 survey of 262 doctors, 1 strongly agree, 5
strongly disagree
16
Visits by Sales Reps to Canadian Doctors
GPs 107, All doctors 262, surveyed in 1995
17
Percent of Canadian Doctors Using Source of
Information
Angus Reid, 1991
18
Quality of Information from Drug
Detailers--France, 1998-2002
Performance of sales representatives in France
still bad Prescrire International 200312153-4
19
Quality of Prescribing and Detailers
20
Samples
21
Number of Samples for Selected Products, Canada
2000
IMS Canada, 2001
22
Drug Samples and Prescribing
Boltri et al. Family Medicine 200234729-31
23
Proposed Policy for University Health Network
(Largest Hospital System in Canada)

• Drug samples intended for personal use
• by UHN staff (i.e., self-treatment or
• treatment of family members) are not
• allowed

24
(No Transcript)
25
What Happened to This Proposal?

• MEDICAL ADVISORY COMMITTEEUNIVERSITY HEALTH
  NETWORKHighlights Thursday, May 13, 2004
  Minutes
• The section addressing use of drug
• samples by physicians and staff has been
• removed from the document.

26
Gifts, Trips and Other Interactions
27
Gifts and Reciprocity
Hare Krishnas
Los Angeles International Airport
28
Gifts to Psychiatric Clerks, Interns and
Residents

• Mean value of gifts 60 (range 0 to 800).
• 37 reported attending dinners, 43 reported
  receiving books.
• The number of promotional items received was
  positively correlated with the belief that
  discussions with reps have no impact on
  prescribing behavior.
• 42 disagreed with the statement I would
  maintain the same degree of contact with reps if
  no gifts were distributed.

CMAJ 1995153553
29
Perceived Influence of Pharmaceutical Reps on
Prescribing
Plt.0001
You
Other Physicians
Am J Med 2001110551
30
Free Trips and Prescribing
31
Formulary Additions and Interactions with
Industry

• Case-control study at a University Hospital in
  the United States
• Cases 40 physicians who had requested formulary
  additions.
• Controls 80 physicians who had made no such
  requests.
• Information regarding interaction with drug
  companies obtained by survey instrument.

JAMA 1994271684
32
Results of Interactions with Industry
Formulary requests were independent of the merits
of the companys drug.
33
Criteria for Causality and Industry-Physician
Interaction
More than one study found effect for
interaction Only one study examined
specificity and defined it as increased
likelihood of choosing sponsors product Wazana.
JAMA 2000283373-80
34
Medical Journals and Industry
35
Revenue from Journal Reprints

• BMJ website Nov. 2001
• Reprints are invaluable for direct marketing,
• exhibitions/seminars and sales support
• campaigns and for mailing new product
• information to doctors and for distribution to
• conference delegates and visitors at
• exhibitions

36
Revenue from Journal Reprints

• Richard Smith, former BMJ editor
• Publish a trial that will bring US 100,000 of
• profit or meet the end-of-year budget by firing
• an editor
• PLoS Med 20052(5)e138

37
Medical Associations and Journal Revenue
Glassman et al WJM 1999171234-8
38
Journal Editors and Conflict of Interest
39
Reluctance to Run Critical Articles

• Transplantation and Dialysis rejected editorial
  questioning value of epoetin in end-stage renal
  disease
• Letter from editor to author
• I have been over-ruled by our marketing
  department with regard to publishing your
  editorialthe publication of your editorial
  would, in fact, not be accepted in some
  quartersand apparently went beyond what our
  marketing department was willing to accommodate
• Dyer. BMJ 2004328244

40
Does Ad Revenue Bias Journal Content?

• Annuals of Internal Medicine, June 1992
• Article analyzing 102 journal advertisements from
  10 leading medical journals
• Expert reviewers
• 44 ads lead to improper prescribing
• 34 ads needed major revisions
• 28 ads should not have been published
• Wilkes et al. Ann Intern Med 1992116912-9

41
What Happened to Ad Revenue?
Landefeld et al JGIM 199510(Suppl)111
42
Why Did This Happen?

• Robert Fletcher (co-editor of Annals)
• The episode revealed the true colours of the
• pharmaceutical industry, which was willing to
• flex its considerable muscles when it felt its
• interests were threatened.
• Fletcher. Lancet 200336110

43
Doctors Attitudes
44
Do Doctors Know If Theyre Being Influenced?
Avorn et al. Am J Med 1982734-8
45
Do Doctors Know If Theyre Being Influenced?

• Impaired cerebral blood flow is a major cause of
  senile dementia
• 71
• Cerebral vasodilators useful in managing
  confused geriatric patients
• 32
• Darvon (dextropropoxyphene)
• stronger than ASA--49
• equivalent to ASA--31
• weaker than ASA--20

Avorn et al. Am J Med 1982734-8
46
Source of Information for British Doctors, 1984-85
Principal general medical practitioners,
minimum no. respondents 203
Greenwood, unpublished PhD thesis
47
Views on Four Drugs

• Same group of doctors (234 respondents) - percent
  favouring commercial vs. general medical view
• Drug A 77
• Drug B 55
• Drug C 28
• Drug D 13

48
Conclusions

• Interactions between drug companies and doctors
  are inevitable at some level
• The interests of drug companies and doctors are
  not always compatible
• Doctors do not always perceive that they can be
  influenced by drug companies
• Ignorance is not bliss
• Drug companies are doing what is best for them
• Its up to the medical profession to do what is
  best for our patients